EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.

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Summary of Job

Perform provider and member outreach to reconcile member records and validate data entry to support continuous quality improvement in Healthcare Effectiveness Data and Information Set (HEDIS) rates and STAR measures for the enterprise.   Facilitate provider and member outreach supporting the MTM, OMW, and Medication Adherence quality measures to ensure member receipt of important clinical services to improve member health outcomes.  Daily telephonic outreach to secure appointments with pharmacists and/or vendors to close gaps in care.  Support efficient medical record retrieval for HEDIS medical record review and HEDIS supplemental data collection activities.  Track calls for all lines of business related to the MTM, OMW, and Medication Adherence quality measures, reporting weekly completion statistics.  Produce and process department mailings to members and physicians.  Monitor internal mailboxes for department faxes and calls.  Collaborate with internal departments in order to administer the MTM, OMW, and Medication Adherence quality measures.

Responsibilities

• Work closely with Clinical Pharmacist(s), Registered Nurses and Data Analyst(s) to prioritize members for outreach who fall in HEDIS measures including but not limited to Medication Adherence and OMW (Osteoporosis Management in Women who had a fracture) and the STAR measure MTM (Medication Therapy Management) Program. 
   
• Perform daily telephonic outreach to secure appointments with pharmacists and/or vendors to close gaps in care supporting Enterprise goals.
   
• Perform daily provider and member outreach supporting the MTM, OMW, and Medication Adherence quality measures to ensure member receipt of important clinical services to improve member health outcomes. 
   
• Prepare and execute member and provider mailings.
   
• Collaborate with providers and internal departments to ensure the receipt and correct processing of all supplemental data related to HEDIS claims and records and assist in correcting discrepancies.
   
• Maintain high data integrity while adhering to HIPAA standards and protecting patient information.
   
• Perform provider outreach to verify and document member’s appropriate medical diagnoses and subsequent treatments both by telephone and in writing.
   
• Coordinate call tracking and provide statistics to stakeholders.
   
• Intake and organize data from other departments while ensuring proper compliance with all CMS regulations, policies and procedures.
   
• Other duties/projects as assigned.

If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law. 

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.